Center for Tobacco Control Research and Education, Institute for Health Policy Studies, Cardiovascular Research Institute, Center for AIDS Prevention Studies, University of California, San Francisco, California, USA

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The most widespread and popular strategy for reducing tobacco use has been “youth access” laws, which make it illegal to sell cigarettes to teenagers. In the USA, youth access controls have been part of tobacco control policies required by the federal government in order to obtain funding for substance abuse programmes1; they were at the core of the tobacco regulation proposed by the Food and Drug Administration2 and struck down by the US Supreme Court. Both the US Centers for Disease Control and Prevention3 and the Institute of Medicine4 recommend youth access controls as part of a comprehensive tobacco control program. By August 2001, in the USA all 50 states and 1139 local governments had passed youth access laws (American Nonsmokers' Rights Foundation database, 24 August 2001).

Unfortunately, while these programmes do make it difficult for teens to purchase cigarettes,5–7 on the whole they do not affect teen smoking prevalence8 (fig 1). Proponents of youth access programmes have argued that this approach would be effective, if only the programmes were “done right” and successfully prevented a high proportion of youth from using commercial sources to buy cigarettes,9 and that exceeding a high “threshold” level of merchant compliance9–14 is necessary to affect youth smoking. There is no consistent empirical evidence to support the existence of this hypothesised threshold8 (fig 1).

This graph shows the relation between 30 day teen smoking prevalence and the level of merchant compliance with youth access regulations in different communities. There is no relation between teen smoking prevalence and the level of merchant compliance with youth access policies. There is no evidence of a threshold effect. From Fichtenberg and Glantz8, with permission of the publisher. (See paper for more details on methodology.)

The paper by Jones and colleagues15 in this issue of Tobacco Control explains why enforcement of youth access laws does not affect teen smoking. Using data from the Youth Risk Behavior Survey to describe the usual sources of cigarettes for high school student smokers, they found that in addition to purchasing cigarettes from stores, students give others money to buy cigarettes, borrow cigarettes from others, and sometimes steal them or use vending machines.15 From 1995 to 1999, significantly fewer student smokers purchased cigarettes in stores, while significantly more gave others money to buy cigarettes.15 Consistent with earlier studies,13,14,16,17 they15 conclude that as youth access laws make it harder to purchase cigarettes, teens simply use other means to get cigarettes. They conclude, correctly, that the effectiveness of tobacco access laws are undermined by these other “social sources” of cigarettes. They recommend stricter enforcement of tobacco access laws and interventions to reduce social sources of cigarettes.

This recommendation is bad policy for four reasons. Firstly, there is no consistent evidence that increased enforcement of youth access laws affects youth smoking8 (fig 1). These results are not surprising because, although most smokers start experimenting with cigarettes in their teens, few teens smoke daily. Indeed, the majority of teen smokers are “experimenters” who have smoked less than 100 cigarettes in their lifetime.18 It is virtually impossible to locate and target the few cigarettes needed to drive these irregular light smoking patterns. Secondly, trying to restrict “social sources” of cigarettes is impractical, blames children, their friends and parents, may lead to laws criminalising children for possession of cigarettes,19 and further diverts attention from tobacco industry marketing practices. Indeed, Philip Morris has embraced this tactic, and is actively promoting messages telling parents to keep their cigarettes away from their kids.20,21 Thirdly, this message is unlikely to resonate with teens, since one of the strongest perceived benefits of smoking is using cigarettes as a way to connect with others, particularly in the face of opposition.22 Fourthly, and most important, there is no evidence to suggest that trying to restrict social sources of cigarettes would work any better at reducing teen smoking prevalence than restricting commercial access.

It has been argued that even if they do not affect youth smoking prevalence, youth access programmes are valuable because they are politically safer than policies involving clean indoor air or anti-tobacco media campaigns, and that they engage the public and help build coalitions for tobacco control.5,23 While this may be true for tobacco control advocates, it is even more true for the tobacco industry.

RETAILER TRAINING TO FIGHT TOBACCO CONTROL

Retailer training programmes focusing on youth access have facilitated tobacco industry development of a badly needed network at the local level to help defeat tobacco control efforts. This network has provided the industry with an extensive “early warning” network to identify emerging threats of the full range of tobacco control policies.24–26

By 1992 the Tobacco Institute was using its “It's the Law” programme (fig 2), which nominally trained retailers to ask purchasers for identification, alongside its efforts to urge retailers to monitor for local tobacco control efforts, including self service cigarette display bans and public smoking restrictions, so the Tobacco Institute could mobilise them to fight these tobacco control efforts: “For monitoring purposes, we [the Tobacco Institute] fund our allies in the convenience store groups to regularly report on ordinance introductions and assist in campaigns to stop unreasonable measures . . . Promotion of The Institute's “It's the Law” programme and other industry programmes play a helpful role was well.”24

Photograph of entrance to convenience store in California showing side-by-side comparison of tobacco industry “It's the Law” youth access notification and a corresponding notification from the California Department of Health Services. The messages are indistinguishable. Indeed, the tobacco industry message is clearer and stronger than the one from the Health Department.

Philip Morris took over the “It's the Law” programme in 1994. A 1994 speech by Ellen Merlo, senior vice president of corporate affairs at Philip Morris, details how alliances with local retailers allowed the industry to fight legislation: “ . . .with . . .local activity rampant, we realized we had to have some way to control the bleeding. We needed an effective system to let us know when and where local laws were being proposed, either at town meetings, in the local city councils or by Boards of Health. Working with the New England Convenience Store Association and other tobacco companies, we developed a network whereby local retailers could assist us by providing information on legislative activities in every Massachusetts Community. We've discovered that if we have enough advance notice to do some homework and get somebody there for the public hearing, we can make a difference.”25

The convenience stores also provide coverage for the industry to fight a wide range of effective tobacco control policies, including clean indoor air.27 For example, in Ohio, Philip Morris gained endorsements from the Ohio Grocers Association, the Ohio Association of Convenience Stores, the Ohio Petroleum Retailers and Repair Association, and the Ohio Petroleum Marketers Association for its “Ask First/It's the Law” programme.28 These organisations later provided Philip Morris29,30 cover for working to pass a law preempting the ability of local boards of health to enact smoke free workplace and restaurant regulations.31 When this legislation was proposed in the state legislature in 1995, the restrictions on local boards of health were hidden in what appeared to be primarily youth access legislation, entitled “The Comprehensive Smoking Regulation and Prevention of Youth Access to Tobacco Act of 1995”.32 The Ohio Council of Retail Merchants, the Ohio Grocers Association, the Ohio Association of Convenience Stores, the Ohio Petroleum Retailers and Repair Association, and the Ohio Petroleum Marketers Association joined with restaurant, licensed beverage, and vending associations supporting this bill, while tobacco companies avoided mention.30,31,33 Philip Morris also drafted letters and phone scripts to contact individual retailers urging them to write their legislators to support this bill.34–37 The bill was defeated, but reappeared in 2001, when the primary public support for a bill restricting health boards' ability to make local smoking policies was the Ohio Council of Retail Merchants.38 The tobacco industry stayed out of the public eye, and politicians supporting Philip Morris' bill claimed they were simply supporting merchants.39–42

OTHER BENEFITS TO THE TOBACCO INDUSTRY

Youth access programmes have also been widely supported by the tobacco industry,43 perhaps because they reinforce the industry's key marketing message that “smoking is for adults”, which arguably makes smoking even more attractive to teens.44 The industry has widely publicised its own youth access programmes, such as “It's the Law”, “We Card”, and “Action Against Access”. Some5,45 have argued that the industry programmes are “bad” in comparison with the “good” programmes run by health groups because they do not include vigorous enforcement efforts. To the general public, however, these programmes are indistinguishable (fig 2).

These programmes have helped the industry fight effective tobacco control legislation and educational programmes by creating the illusion that they are doing something. They can also bolster industry credibility. Philip Morris has monitored the effect of their “Action Against Access” programme on smokers' awareness that Philip Morris started the programme, and how the programme affected consumers' feelings about their company.46–48 Philip Morris's 1995 “Talking points to key customers on youth issue” emphasises how Philip Morris could benefit in the long term if it took the lead in addressing the sensitive “youth access” issue: “If we can frame proactive legislation or other kinds of actions on the Youth Access issue, if we can get out in front on this issue now, if we can seize the moral high ground, we will not only be doing the right thing, we will be protecting our industry for decades to come49 [emphasis in original].

A 1991 Tobacco Institute discussion paper noted: “Broad-based advertising [of industry youth programmes] . . .has the important effect of making the public aware that the industry says it is trying to do the right thing . . .”50

The tobacco industry's vocal support of youth access programmes is similar to tobacco industry “accommodation” campaigns in response to pending clean indoor air laws.27 Accommodation campaigns aim to convince decision makers that legislation (such as smoke-free bars or restaurants) is unnecessary because establishments can take voluntary action to accommodate smokers and non-smokers.27 The accommodation message allows the tobacco industry to take a political stance that appears reasonable: “we want to accommodate both smokers and non-smokers” and that makes health advocates appear extreme when advocating for clear indoor air. Similarly, youth access programmes allow the tobacco industry to appear to want to discourage youth smoking, thus seizing the “political centre” and “forcing health advocates to the extreme”.50 In fact, the Tobacco Institute strategy planned to “bait anti-tobacco forces to criticize industry efforts” and “focus media on anti's extremism”.50 The suggestions by Jones and colleagues15 and others5,14 to try to stop teens from obtaining cigarettes from their friends or parents will be even easier for the industry to paint as “extreme”.

In addition to using youth access programmes to fight more effective policies, the tobacco industry has reaped several other benefits. Tobacco industry youth access messages (which do not contradict cigarette advertising) have allowed the industry to create competition with other media campaigns (such as the “Truth” campaign which exposes tobacco industry manipulation of teens) which actually affect teen smoking prevalence.51–55

CONCLUSION

At best, youth access programmes are ineffective and a drain on limited resources. Even if they did affect youth smoking, the impact on smoking prevalence and morbidity and mortality from smoking would not be seen for decades.56 At worst, they are counterproductive and help the tobacco industry fight meaningful tobacco control policy. While youth access programmes seemed logical and well meaning, the simple fact is that they do not work and are now leading into even more futile efforts to control “social sources” of cigarettes.

It is time for public health practitioners to recognise that the balance of empirical evidence shows that youth access is a failed strategy and abandon it. Youth access should be removed from recommendations for comprehensive tobacco control programmes. Instead, tobacco control advocates should pursue strategies which have solid empirical evidence of effectiveness, such as smoke-free workplaces and homes,57–60 taxes,57–59,61,62 media campaigns,63 and secondhand smoke messages.64

Acknowledgments

This work was supported by NIH Grant T32 MH-19105 and National Cancer Institute Grant CA-87472.

Youth access has benefited the tobacco industry

REFERENCES

US Department of Health and Human Services. Substance abuse prevention and treatment block grants: sale or distribution of tobacco products to individuals under 18 years of age (45 CFR Pt. 96). Federal Register1993;58:45156–74.

Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control program – August 1999. Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, Office on Smoking and Health, August 1999.

Haviland ML. Comparison of Legacy's truth with the Philip Morris Campaign. Abstract presented at the American Public Health Association annual meeting, 2001.

Moon-Howard J, Arnold E, Haviland ML. Assessing the efficacy of anti-smoking messages for urban youth at risk: a comparison of the American Legacy Foundation and Philip Morris ad campaigns. Abstract presented at the American Public Health Association annual meeting, 2001.

US Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta, Georgia: US Deparment of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health, 2000.

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